After The Reconstruction

Contents
 
 

Introduction to Breast Balancing Procedures

Breast balancing procedures refer to operations on the remaining natural (non-reconstructed) breast. These may be performed in order to achieve closer symmetry between the two sides. When choosing a method of breast reconstruction, it is often possible to select a technique that will closely match the natural breast in size and shape. Other times, the method chosen may require an alteration of the natural breast in order to achieve symmetry. This is especially the case in women with very large breasts or breasts that have a considerable amount of ptosis (i.e. droopiness). Some patients may request surgery on the normal breast for either cosmetic or functional reasons.

Available techniques include breast reduction, mastopexy (i.e. a breast lift), breast augmentation, or a combination of these techniques. See Figure 1 for a video demonstrating the mastopexy procedure. The selection of the type of "balancing" procedure depends on the size of the natural breast, the type of breast reconstruction performed, and the patient's wishes for the resultant size of both breasts. These procedures often require another general anaesthetic and can sometimes be performed at the same time as the nipple and areola reconstruction on the reconstructed breast.

(The schematics and movie in the in the Breast Reduction, Breast Lift and Breast Augmentation sections demonstrate the respective procedures on both breasts. However, for breast reconstruction patients, the same techniques can be used on the remaining natural breast in order to achieve symmetry between the two breasts)

 

  

Figure 1 - This short video schematically demonstrates a mastopexy (i.e. a breast lift) and describes reasons for having a breast reduction or augmentation. (Quicktime movie - click on graphic to launch in new browser window)
 

Breast Reduction

A breast reduction may be required if the patient's natural breast is much larger than the reconstructed breast. Most times, this will be obvious even before the breast reconstruction has been performed and will be mentioned to the patient as part of the initial consultation and plan.

How is the procedure performed?

In a breast reduction, the surgeon removes fat, breast tissue, and skin from different parts of the breast. The nipple and areola is then moved upwards and the tissues are closed around the new nipple location to form a smaller and more "lifted" breast. See Figures 2 to 5 for schematics demonstrating this procedure. Please note that these diagrams show the procedure on both breasts, and in this particular situation, such a procedure would only be performed on the remaining natural (non-reconstructed) breast.

 

Figure 2 - This schematic shows a woman with very large breasts.


 

Figure 3 - This schematic demonstrates how the nipple and areola complex is moved to a higher location in the reduced breast.

 
 

Figure 4 - This schematic demonstrates the final area requiring a sutured closure.

 
 

Figure 5 - This schematic demonstrates an idealized final result.
 

Scars

In all cases, a scar is produced that encircles the areola. There is also a vertical scar that goes from the areola to the underside of the breast. Sometimes these are the only new scars. However, many times there is also a horizontal scar along the underside of the breast (see Figure 5).

Advantages of a Breast Reduction

  • the reduced breast will more closely match the shape of the reconstructed breast
  • the reduced breast will be smaller, which may relieve strain on the back and neck

Disadvantages of a Breast Reduction

  • a breast reduction is additional surgery
  • it leaves permanent scars on the natural breast
  • the nipple and breast skin may have less sensation than before the surgery
  • there may be some interference with breast feeding


Mastopexy (Breast Lift)

A mastopexy (i.e. a breast lift) may be required if the patient's natural breast is either somewhat larger than the reconstructed breast or is very ptotic (i.e. droopy). Most times this will be obvious even before the breast reconstruction has been performed and will be mentioned to the patient as part of the initial consultation and plan.

How is the procedure performed?

A breast lift is very similar to a breast reduction. However, less (if any) fat and breast tissue is removed. The removal of skin tends to move the nipple upwards and since there is less skin, the breast itself is higher and firmer after surgery. See Figures 6 to 9 for schematics demonstrating this procedure. Please note that these diagrams show the procedure on both breasts, and in this particular situation, such a procedure would only be performed on the remaining natural (non-reconstructed) breast.

 

Figure 6 - This schematic shows a woman with ptotic (i.e. drooping) breasts.


 

Figure 7 - This schematic demonstrates how the nipple and areola complex is moved to a higher location in the reduced breast. Note that minimal (or no) breast tissue or fat is removed during a mastopexy (as compared to a breast reduction).

 
 

Figure 8 - This schematic demonstrates the final area requiring a sutured closure.

 
 

Figure 9 - This schematic demonstrates an idealized final result.
 

Scars

In all cases, a scar is produced that encircles the areola. Sometimes, this is the only new scar. However, most times there is also a vertical scar that goes from the areola to the underside of the breast and a horizontal scar along the underside of the breast (see Figure 9).

Advantages of a Breast Lift

  • the lifted breast will more closely match the shape of the reconstructed breast
  • the lifted breast will be higher and firmer after surgery

Disadvantages of a Breast Lift

  • a breast lift is additional surgery
  • it leaves permanent scars on the natural breast
  • the nipple and breast skin may have less sensation than before the surgery
  • there may be some interference with breast feeding


Breast Augmentation (Breast Implants)

A breast augmentation may be performed if the patient's natural breast is much smaller than the reconstructed breast. However, most times it is not difficult to match a small natural breast with the reconstruction. Therefore, most commonly a breast augmentation is performed on the natural breast because the patient has decided that she wants to have larger breasts after her reconstruction.

How is the procedure done?

The procedure is similar to a breast reconstruction using tissue expanders and breast implants. An incision is made in one of three typical places in order to insert the breast implant. Most commonly, the incision is placed either under the breast in the natural fold or around the areola. Another possible location for the incision is in the axilla (i.e. the "armpit"). A breast implant is then placed either above or below the pectoralis muscle, depending on both patient and surgeon preferences. See Figures 10, 11 and 12 for schematics demonstrating this procedure. Please note that these diagrams show the procedure on both breasts, and in this particular situation, such a procedure would only be performed on the remaining natural (non-reconstructed) breast.

Scars

There will be a short linear scar (3 to 4 cm in length) in the area from where the breast implant was inserted. Depending on the site used to insert the implant, the scar will be in different locations (e.g. under the breast, around the areola or in the axilla) (see Figure 12).

Advantages of a Breast Augmentation

  • the augmented breast will more closely match the shape of the reconstructed breast
  • the patient will have larger breasts

Disadvantages of a Breast Augmentation

  • a breast augmentation is additional surgery
  • it leaves more permanent scars
  • the nipple and breast skin may have less sensation than before the surgery
  • there may be some interference with breast feeding
  • the implant may develop complications over the years (e.g. leaks, rupture, or a capsular contracture), which may need to be corrected by extra surgery
  • the implant will make mammograms on the nonreconstructed breast more difficult to perform

 

Figure 10 - This schematic shows a woman with small breasts.


 

Figure 11 - This schematic shows the three possible locations for an incision used to insert the breast implant.

 
 

Figure 12 - This schematic demonstrates an idealized final result.
 

Introduction to Umbilical Reconstruction

Some surgeons prefer to remove the patient's own umbilicus during a pedicled TRAM flap procedure. This is because the process of suturing the fascia after the rectus abdominis muscle is removed "pulls" the umbilicus off to the side. Therefore, the resultant final position of the belly button can be "off-center". As such, it may be preferable to remove the patient's own umbilicus and construct a "new" one in the appropriate midline location.

How is the procedure performed?

There are several methods of reconstructing the umbilicus. In general, the desired location of the new umbilicus is first determined and marked out (see Figure 13). Then, small incisions are made in the skin in this area. The underlying fat is then removed (this causes the indentation of the new umbilicus). The skin is then sutured in a particular fashion to further create the new umbilicus (see Figures 14 and 15).

 

Figure 13 - The patient shown here has the preoperative markings for an umbilicus reconstruction.


 

Figure 14 - This is the same patient shown immediately postoperatively (still on the OR table).

 
 

Figure 15 - This is the same patient shown immediately postoperatively from the side (still on the OR table). Note the indentation of the new umbilicus.
 
 

Scars

There will be a scar in the area of the new umbilicus. However, this is purposeful as it is the scar that creates the indentation and shape of the new umbilicus.

When should umbilicus reconstruction be performed?

The timing of an umbilical reconstruction depends on several factors, including surgeon and patient preferences. Umbilicus reconstruction can be done at the conclusion of the TRAM flap procedure. It can also be done later on an outpatient basis or during a general anaesthetic for other procedures (such as nipple and areola reconstruction).

Advantages of Umbilicus Reconstruction

  • if the patient's own umbilicus was removed, a reconstruction will create an indentation in the abdominal area which looks like an umbilicus
  • the new umbilicus will be centrally located

Disadvantages of Umbilicus Reconstruction

  • it is an additional surgical procedure which produces a new scar
  • a reconstructed umbilicus may not look exactly like the original
  • it may require a short recovery period

Indications for Umbilicus Reconstruction

Any patient who has had a breast reconstruction, which removed their umbilicus in the process, is a candidate for this procedure.

Contraindications for Umbilicus Reconstruction

In general, there are no contraindications to this procedure.

Recovery Time

The procedure usually requires about 30 minutes to complete. Most patients will have some pain or discomfort in the area, but this is usually treated adequately with analgesics. Most patients will resume their normal daily activities within a week or two after the procedure.

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